The Health Sqyre Insurance Guide: Understanding Your CPAP Coverage, Claims & Cost

Thinking about buying CPAP equipment to treat your obstructive sleep apnea? Wondering if health insurance covers CPAP machines, CPAP masks, and accessories? This comprehensive guide will answer all of your questions about health insurance and CPAP therapy.

How does health insurance work?

Understanding health insurance coverage and pricing can be frustrating. How are insurance prices determined? Are you getting the price based on your insurance plan? Although each insurance provider and plan is different, there are three important numbers  to keep in mind when shopping for durable medical equipment (DME) with insurance: your deductible, your co-insurance rate, and your out-of-pocket-maximum

  1. Deductible: Your deductible is the amount you must pay out-of-pocket in medical expenses before your co-insurance rate kicks in to lower your share of the cost.
  2. Co-Insurance Rate: Your co-insurance rate is the percentage of a medical expense that you are required to pay after you have met your deductible. 
  3. Out-of-Pocket-Maximum: Your out-of-pocket maximum is the most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but does not include your regular premiums.  

For more information on the details of health insurance and examples of different deductibles, co-insurance rates, and out-of-pocket maximums in action, please refer to our blog post  “How Does Insurance Work And How Is It Calculated?” or Insurance Term Glossary.

To see how your personal deductible, co-insurance rate, and out-of-pocket-maximum are influencing  the price of your CPAP supplies, link your insurance information to Health Sqyre with the button below.

What CPAP supplies are covered by health insurance?

After gaining a basic understanding of the numbers behind health insurance pricing, the next logical question is: What CPAP supplies are covered by health insurance? 

Any product that has an associated HCPC code is covered by insurance, and therefore is eligible for insurance reimbursement. Although coverage may vary by the health insurance provider, most private providers follow Medicare’s guidelines for insurance-eligible products. The following CPAP products listed under  Medicare’s reimbursement schedule are COVERED by health insurance:

Heated Tubing

Hybrid Masks

Replacement Hybrid Mask Cushions

Replacement Hybrid Mask Nasal Pillows

Full Face Masks

Replacement Full Face Mask Cushions

Nasal Masks

Replacement Nasal Mask Cushion

Replacement Nasal Pillow

Nasal Pillow Mask

Chinstraps

Tubing

Disposable Filters

Non-Disposable Filters

Oral Interface Masks

Replacement Humidifier Chambers

BiPAP Machines

BiPAP Auto Machines

Non-heated CPAP Humidifiers

Heated CPAP Humidifiers

CPAP Machines

Headgear

What CPAP supplies are NOT covered by health insurance?

Medicare, and therefore most private insurance providers, will NOT cover the following CPAP products:

Cleaning Supplies: SoClean CPAP Sanitizer, Lumin Bullet, Mask Wipes, etc.

Comfort Products: Mask Liners, Creams, etc.

Power Supplies: CPAP Power Cords and Batteries

Travel CPAPs: Insurance companies do not cover travel CPAP machines because they are seen as supplementary CPAP machines.

Although insurance providers will not cover CPAP supplies listed above, Health Sqyre can still find you with the best cash price available from our DME vendors. Shop now for great deals on your cleaning, comfort, power, and travel CPAP products!

Health Insurance Compliance and Documentation Requirements:

Like home and auto insurance, using health care insurance requires lots of documentation. Health insurance companies usually require the following forms of documentation before reimbursing your CPAP supplies:

 

A Prescription (RX) – A prescription is an instruction written by a medical practitioner that authorizes a patient to be provided a medicine or treatment. 

If your CPAP prescription is out of date, but you need to buy new CPAP supplies, do not worry! Health Sqyre offers a telemedicine prescription package – 24 hour  turnaround, and no trip to the doctor’s office!

Assignment of Benefits (AOB) – An AOB is an arrangement by which a patient requests that their health benefit payments be made directly to a doctor or hospital. 

Medical Records (e.g. Sleep Test Results) – Medical records refer to a record of a patient’s medical information. When purchasing CPAP supplies, insurance companies usually require prior  sleep study records to confirm the necessity for CPAP therapy. Usually taken at a sleep center, a sleep study determines your necessity for CPAP therapy by measuring your Apnea Hypopnea Index (AHI) during a night of sleep.

If you think you have sleep apnea, but have never taken a sleep study, you can purchase a Home Sleep Test from Health Sqyre. With our HST package, there is no need to go to a sleep center to get a sleep study! You can take our HST from the comfort of your home. If medically necessary, one of our sleep specialists will analyze your HST results and recommend a CPAP machine and ideal air pressure to treat your sleep apnea.

Prior Authorization – a process by which health insurance companies determine if they cover a prescribed procedure, service, or medication. Air pressure

Doctor’s Notes – Doctor’s notes are entries  in medical records made by a physician or nurse. 

Compliance – Compliance refers to a set of insurance guidelines determining if a patient is using their CPAP therapy equipment enough to receive insurance coverage. Simply put, compliance is defined as use of PAP devices for 4 or more hours per night on 70% of nights (21 out of 30 nights) during a consecutive 30-day period. 

For more information on insurance compliance, please refer to our “How to Be Compliant Help Page”.

 

Although the above list of requirements may seem intimidating, getting a good night’s sleep should not be complicated! When shopping with health insurance on Health Sqyre, we will work with you every step of the way to make the process as simple as possible!

How does health insurance reimbursement work?

Step 1. Complete an out-of-network claim form

These forms should be readily accessible on your insurance company’s website 

Step 2.  Attach your itemized receipt

      We will always include a receipt with your purchase and package.

Step 3. Submit the claim form and receipt to your insurance company

Step 4. Collect your reimbursement!

     Typically, this process takes 2-3 weeks (can vary based on your provider).

How to use your health insurance when shopping with Health Sqyre:

For specifics on linking your insurance with Health Sqyre, please refer to our “How to Use Health Insurance at Health Sqyre Guide”.

What health insurance companies does Health Sqyre work with?

Although Health Sqyre currently does not work with Medicare and Medicaid services, we hope to in the future! Enter your email below to be notified when we add Medicare and Medicaid services!

Share
Recent Posts